A Critical Analysis of Typhoid in the United Statesat the Turn of the 20th Century
Fluidivas: Lindsey Ehinger, Kim Wilson, Stephanie Wedekind, Laura Mar
Abstract
At the turn of the 20th centurytyphoid was prevalent in U.S. cities, and many different and interrelated efforts were implemented to control the disease. As a result, the definitive cause for the decrease in typhoid incidence is a subject of great debate. After researching possible causes for the decline, it is evident that filtration and chlorination in the water treatment processes werefactorsin decreasing the spread of typhoid via the fecal oral route. However, because many cities experienced a decline in typhoid mortality prior to the use of filtration and chlorination, other factors must have been significant. Of the other factors examined, it was found that education and public awareness of sanitation alone did not have a considerable impact on typhoid incidence. Also, it was found that food quality aspects such as pasteurization and refrigeration occurred too late to impact the initial decline of typhoid mortality. Filtration and the increased use of ice for food storage were found to be the most significant factors in the decreasing rate of typhoid mortality in the United States.
Introduction
Typhoid has infected people for hundreds of years; it was first identified and named in the 1880s (Mikkelson, 2002). Typhoid is an acute enteric infection caused by the Salmonellatyphi bacterium which only infects humans, surviving in the intestinal tract and bloodstream. The infectious dose is 15-20 cells, dependent on the person’s age, health, etc. (U.S. Food & Drug Administration, 1992). Carriers, people who carry the bacteria without symptoms, and symptomatic patients “shed” the bacteria in their infected feces. Typhoid is spread by ingesting food or water that has been contaminated by Salmonellatyphi. People can contract typhoid from fecal contaminated drinking water or foods washed by contaminated water. Someone carrying the disease can contaminate food or water by handling it (CDC, 2004). Once typhoid is contracted the symptoms can be quite severe or barely noticeable with common features of a high fever, stomach pains, headache, and in some cases, a red rash. In the 1880s through the early 1900s many epidemics broke out resulting in the death of hundreds of people. At that time there was no known cure for typhoid; it killed one in ten people. In 1948, antibiotics were developed to cure the infected person, but one in one hundred people continue to die from typhoid, with a much higher mortality rate in undeveloped countries (Mikkelson, 2002).
Objectives
In order to better understand the disease, there have been many studies done as to why there was a sharp decrease in the number of typhoid cases in the late 1900s and early 20th Century. The improvement in health is often attributed to filtration and disinfection in water treatment. However, improved sanitation practices, education and public awareness, and better food storage and quality are also factors that may have decreased the spread of typhoid. By examining how typhoid mortality trends correlate with historic changes, the objective is to determine which factors are most significant in reducing typhoid in the United States. Case studies and health reports from the U.S. and abroad will provide relevant data to be analyzed.
Results and Discussion
The Role of Filtration
In the late 1880s, Louis Pasteur developed the “Germ Theory” of disease and exposed the role of microscopic organisms in transmitting disease through water. As a result, scientists in the early 19th century began to think of ways to decrease disease-causing pathogens in the water supply. In order to reduce the turbidity that harbored pathogens, scientists began experimenting with water filtration (EPA, 2000). Rapid Sand Filtration was first introduced to the United States in 1882 at the Hackensack Water Company site in Oradell, New Jersey. Rapid Sand Filtration removes small particles from incoming river water before it is discharged to local towns and communities (HWWC, 1998). Between 1900 and 1915, the death rates from typhoid in the US decreased just as the amount of filtered water increasingly became available (Figure 1).
Figure 1. US Typhoid and filtration trends in early 20th century (Weber-Shirk, 2004).
In Philadelphia in the early twentieth century, the mortality rate drastically declined during the same time filtration was implemented (Figure 2). This was also the case in many cities, including Minneapolis (Figure 2) and Albany (Figure 3).Both of these cities show a decline in mortality rate prior to filtration. The general trend prior to filtration is similar to that of Philadelphia: mortality rate rises and falls, with peaks every couple of years. After the use of filtration, many cities including Philadelphia, Albany, Cincinnati, Pittsburg and Baltimore experienced a continued decrease in mortality rate. In Minneapolis the mortality rate had begun decreasing, but the rate at which it did so increased dramatically after filtration was implemented (Figure 2) (Weber-Shirk, 2004).
Figure 2. Correlation between typhoid mortality rate and interventions in Philadelphia and Minneapolis in the early twentieth century (Weber-Shirk, 2004).
Figure 3. Typhoid mortality trend in Albany, NY. (Data from Schoenen, 2002).
From 1900 to 1913, a study of 20 U.S. cities found an overall reduction in typhoid fever by 65% after filtration was implemented (Table 1). Other cities show no correlation between filtration and the decline in mortality rate. Boston’s mortality rate steadily declined despite lack of interventions such as filtration (Figure 4). Some cities such as Springfield, MA, saw little to no reduction in death rates after the introduction of filtration. The 65% reduction rate cited is deceptive because it implies overall success. In reality of the data shows that ten areas out of twenty had greater than 50% reduction after filtration and the other ten areas had less than 50% reduction (Schoenen, 2002). Therefore this study does not provide conclusive evidence that filtration was successful in reducing typhoid mortality.
Table 1. The mean values for 5 years before and 5 years after the introduction of filtration of public water supplies per 100,000 people shows the reduction of typhoid fever death rate in American cities (Schoenen, 2002).
Figure 4. Typhoid mortality trend in Boston despite interventions (Weber-Shirk, 2004).
Although filtration today is known to effectively remove particles from water (including viruses and bacteria), the first filters could have been flawed in many respects. Because water treatment was created through trial and error, the first filters were experiments. Variables that could have caused malfunction include pore size, frequency of cleaning, and rate of water flowing through the filter; if there is flooding due to large rain events, the filter will fail, unable to handle the unusually high flow rates. When implemented correctly filtration does remove small particles, including typhoid-contaminated fecal particles,which reduces the transmission of typhoid through water. However, the data is inadequate to conclude that filtration is the only contributor to the decrease in typhoid incidences in the early 1900s.
In the cases where filtration was used in the water treatment processes, the number of deaths caused by typhoid decreased at the same time filtration was implemented. After filtration was implemented in many cities, the large fluctuations in typhoid mortality disappear indicating the success of filtrations ability to control the spread of typhoid via the fecal oral route. Some cities did not use filtration but still experienced decreased typhoid mortality and all cities show a decreasing mortality rate prior to filtration. Therefore filtration played an important role in decreasing typhoid incidence, it could not have been the only factor.
The Role of Chlorine Disinfection
Chlorine Disinfection of drinking water was first introduced and implemented in the US in 1908 at Bubbly Creek Filter Plant in Chicago. It was first used by William Soper of England in 1879 to treat feces contaminated with typhoid (Gallagher, 1997). Today 98 percent of water treatment facilities use chlorine as opposed to UV radiation or other methods of disinfection (Moorhead Public Service, 2004). Due to its broad germicidal potency, chlorine kills viruses, bacteria and protozoa in drinking water. It is most effective at low concentrations at a pH of 7-8 when hypochlorous acid (HOCl) can be formed in solution. Chlorination is a good disinfectant because it provides a residual in the distribution system that kills bacteria and prevents microbial re-growth (Gallagher, 1997). However, chlorine is not effective in waters with high turbidities which may result in inconsistent disinfection especially from surface water sources.
Although the decrease in Typhoid cases in many areas in the early 1900s is often attributed to chlorination, it is hard to directly attribute credit chlorination to this decrease. The towns of Pola (1886) and Maidstone (1887) are commonly referred to in order to support the hypothesis that chlorination suppressed the typhoid epidemic. However, the use of chlorine in the water supply did not occur until after the typhoid outbreaks began, making it difficult to conclude that chlorine was the major factor in typhoid reduction. This is the case for many U.S. cities including Lousiville, KY (Figure 5) and Cleveland, OH (Figure 6). These figures show that the major drop in mortality rate had already occurred by the time chlorination was introduced. Therefore, Pola, Maidstone, Lousiville, and Cleveland fail to provide prove a causal link between disinfection and the prevention of typhoid transmission (Schoenen, 2002).
Figure 5. Correlation between chlorination/filtration and decreased typhoid mortality in Louisville, KY(Weber-Shirk, 2004).
Figure 6. Correlation between chlorination/filtration and decreased typhoid mortality in Cleveland, OH (Weber-Shirk, 2004).
Statistics for Milwaukee (1890 to 1930) (see Figure 7) indicate that additional factors are important in the decrease of typhoid deaths. Between 1890 and 1897, typhoid fever mortality dropped significantly despite the fact that water disinfection had not yet been introduced. Between 1910 and 1915, water disinfection was intermittently conducted and death rates decreased. However, in 1911, the mortality rate was very low despite the fact that there was no disinfection taking place. Chlorine disinfection became a regular occurrence in 1915, but there was a significant increase in mortality again in 1916 (Schoenen, 2002). The unsystematic spikes and declines in typhoid mortality in Milwaukee are an indication that no one single factor can be attributed tocredited with causing typhoid mortality in the early 20th Century.
Figure 7. The development of the typhoid fever mortality in Milwaukee between 1890
and 1930 and the drinking water supply (Schoenen, 2002).
Chlorination helps reduce the spread of typhoid via the fecal-oral route because it kills typhoid bacteria when used correctly and fecal concentrations are small. However, in the case of the U.S. in the early 20th Century, chlorination was implemented after typhoid mortality had already decreased dramatically. Consequently, other factors were more important in causing the decline of typhoid mortality in the U.S.
Sanitation and Education
As scientists began to investigate why typhoid fever was so prevalent, recommendations for sanitation were made public. The following investigates how much of an impact education had on the decline in typhoid cases in the 1900s. Factors such as Typhoid Mary and Upton Sinclair’s The Jungle made the public more aware of unsanitary conditions and how to prevent the spread of typhoid. However, the case of the Spanish American War indicates that sanitation recommendations were not followed and therefore cannot be attributed to the decrease in typhoid mortality.
During the Spanish American War (1897-1911), more Americans died from typhoid while training stateside than from yellow fever or from fighting overseas. One-fifth, 20,000, soldiers contracted typhoid resulting in 1,500 deaths. In reaction to the epidemic, the Surgeon General of the U.S. Army George M. Sternberg made many strides to understand and therefore prevent the pervasiveness of typhoid in stateside army camps (UVA, 2004). However, despite attempts to educate, the lack of concern on the part of soldiers and commanders meant that most camps continued to be unsanitary and overrun with typhoid.
In 1897, immediately following the declaration of war, Sternberg issued the Surgeon-General’s Circular No. 1 explaining theories for the origin of typhoid and recommended sanitation practices for army camps. In this circular, Sternberg recognized the danger of polluted water, suggested boiled or filtered supplies for troops, and provided instructions on filtering and testing the water. The circular also specified that campsites should have good drainage and previously occupied sites should be avoided. Latrines or “privy-pits” should be dug at each camp and should be replaced when contents came within two feet of the surface. In order to disinfect fecal matter, the latrines should be covered three times a day with earth, quicklime or ashes. In particular, hospitals should treat fever patient excrement with a disinfecting solution (carbolic acid, chloride of lime, or milk of lime). Unfortunately, despite the circular’s advice, the mortality rate in the U.S. army continued to rise. Regardless of increased knowledge and attempts to educate, people remained dismissive of sanitation. Nurses remained “[w]holly ignorant of the nature of infection and the methods of disinfection,” (UVA, 2004) and continued to handle infected bed pans. As a result, many nurses became ill. It also proved difficult to force soldiers to act in accordance with sanitation requirements, especially while officers were more concerned with war strategy than disease prevention (UVA, 2004).
Of five army corps suffering from epidemic typhoid, only one was successful in actively suppressing the disease. This group took three steps: imposed an effective latrine-policy, disinfected clothing, blankets, and tents of the entire group (15,000 soldiers) and relocated to a new area. Using this camp as an example, new technologies were developed so that simple systems, rather than individuals, could be relied on to treat and maintain waste. The Reed Trough was designed as a multi seat latrine that excluded flies. All excrement traveled through a metal trough where it was disinfected. The Odorless Excavatorwas used to pump the tank with minimal spillage. The Forbes-Waterhouse Sterilizer was used to sterilize water for troops in the field. After the installation of the new devices, the rate of transmission in stateside camps dropped from 85 cases per 1000 soldiers in 1898 to less than 6 per 1000 in 1900 (UVA, 2004). This case indicates that improved sanitation practices decreased the transmission of typhoid fever in the camp. The failure to control typhoid in the other four army camps after continuous warnings indicates that education without action is unsuccessful.
In 1857, the first toilet paper was manufactured. By 1890, Scott Paper Company became the nations leading seller with over 2,000 reselling customers distributors? (Toiletpaperworld, 2003). Toilet paper improved sanitation for those who used it, and the decrease of typhoid cases in the late 19th Century can partially be attributed to this.
In 1906 Upton Sinclair wrote The Jungle exposing the unsanitary condition of the Chicago meat packing industry (CDC, 1999). The book sold over 150,000 copies. After Theodore Roosevelt read Sinclair’s book he ordered an investigation of the meat packing industry. Public awareness increased dramatically after The Jungle leading to the Pure Food and Drugs Act and the Meat Inspection Act of 1906 (Spartacus). This book led individuals to become more aware of the quality of food they were eating.
Another event that increased public awareness was Mary Mallon, nicknamed Typhoid Mary, the most famous “chronic carrier” in the U.S. As a cook for various homes, typhoid outbreaks followed her from job to job between 1900 and 1907. In seven jobs, 22 people became ill and one girl died shortly after Mallon came to work for them (About, Inc., 2004). Through a series of articles (1907-1909) Typhoid Mary became a nationally recognized face illustrating the spread of typhoid via poor hygiene during food preparation.
In the army camps, individuals were educated yet failed to improve sanitation practices illustrating that education without changed lifestyle is not sufficient to decrease the spread of typhoid. Assuming a similar scenario, public awareness would not necessarily lead to changed lifestyle and there is no data to support the claim that education induced action. Therefore, public awareness through education alone did may not have caused thedecrease in typhoid mortalityat the turn of the 20th Century. There is, however, an indication that improved sanitation practices if implemented properly, as illustrated by one army camp, did reduce the spread of typhoid via the fecal oral route.
Food Quality
Since the drop in typhoid mortality coincided with the industrial revolution, a time of great change, it is hard to isolate the factors responsible. However, one possible reason for the decrease in typhoid deaths is the increase use of ice for refrigeration of food. Contaminated food was a widespread source of the transmission of typhoid. In a recent study in Nigeria, it was shown that the risk of contamination of food was much greater when the food was stored at warmer temperatures (Ehiri, 2001). During the mid 1800s the traditional way of storing milk, butter, and other perishables was to keep them in cellars, outdoor window boxes, or underwater in nearby lakes, streams or wells. These methods slowed the process but did not prevent food from spoiling. As a result, it was not unusual to die of “summer complaint” caused by contaminated food (Krasner-Khait, 2004). If stored improperly, the typhoid bacteria would replicate to high levels more likely to infect the consumer. The winters of 1889 and 1890 were unusually warm, leading to a shortage of ice and greater possibility for food contamination via spoiled food(A&E, 2004) which coincideswitha high typhoid mortality at this time in some U.S. citieslike Minneapolis and Albany (Figures 2 and 3).